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Tag: doctor/ patient relationship

“You Doctors These Days Just Want Us To Go off and Die …”

A recent case taught me a lot about how people perceive their medicines.

I was trying to help a 92-year-old man get off some of his medicine. I can’t go into the details, but suffice to say, there was much opportunity to trim a long list of drugs, many of which were threatening his existence and impairing his quality of life.

As I was discussing stopping many of the meds, the patient said (with a quite sincere tone):

“You doctors these days just want us old people to go off and die.”

That was a zinger, a real punch in the gut. I was trying to do the opposite–allow him to live a longer and better life–but the patient perceived me as a mini-death panel.

I’ve been thinking a lot about this case. Why was this man “attached” to his meds? Why had he associated his longevity with chemicals that now threatened his existence?

The answer, I believe, is a knowledge gap. He, like many people, doctors included, fell into the trap of association and causation. He associated his health with his medicines; he overestimated their benefits. He thought the pills were keeping him alive. They were not. He lived despite his medicines.

What I tried to explain to this patient was that benefits from medicines do not continue indefinitely. Things change in the elderly, and, what is for younger patients may not be in the aged.

Take the case of preventing stroke in the elderly. Simple drugs, such as high blood pressure medicines and statins, may no longer offer a net benefit to the patient over the age of 80. Really. It is true.

Let me tell you about a recent commentary in the journal Evidence Based Medicine (from BMJ).

Dr Kit Byatt is a doctor in the UK who specializes in Geriatric Medicine. He wrote this refreshingly concise summaryoutlining four reasons why the medical community should reconsider its overenthusiastic views of stroke reduction in patients over the age of 80. In the title, Dr. Byatt asks whether we are being disingenuous to ourselves and to our elderly patients.

The answer is yes.

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That Vitamin There Could Kill You

Once-upon-a-time, when a patient said they were taking a vitamin, most doctors would simply shrug their shoulders and say, “well, I guess its OK, it couldn’t hurt.”   There was little research to judge the affect of vitamin supplements, so there was no reason to take a stand.  That is no longer true.

Now we have published data on many vitamins and we can say that for most people they do not work.  More importantly, there is increasing research that says manufactured, chemically synthesized nutriment compounds in a pill, can be deadly.

For this reason, I am likely to ask my patients if they are taking a vitamin and, if so, which fabricated additive and how much.  Therefore, I asked Bill, while he was in the office receiving chemotherapy for Hodgkin’s disease, what alternative therapies he was using.

When he informed me that he swallowed a multivitamin (MVI), large doses of Vitamins C and E, as well as a B complex preparation, I advised him to stop.

To my astonishment he responded, “Well, you only want me to do that because you make a lot of money on chemotherapy, and vitamins might put you out of business.”

Bill’s response, he lack of trust in my advice, disturbs me at several levels.  He fails to understand and does not wish to learn the present state of science regarding nutrition. In addition, there is a major problem regarding his perception of my motivations and therefore the veracity of my guidance.

Let us be clear; in the absence of malnutrition, malabsorption and a few uncommon medical conditions, there is absolutely no reason to take a multivitamin.  They do not prevent or fix anything.  Originally developed for starving populations and hungry soldiers during the Second World War, they have no place in a society with access to a broad range of foods.

More importantly, there is increasing data that people taking a multivitamin may become less healthy.

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The Black Box at the Center of Health Economics

When Michael injured his knee, he did what any responsible person would do.  He was not incapacitated, and though the knee was painful and swollen, he could get around pretty well on it.  So he waited a few days to see if it would get better.  When it didn’t, he saw his primary care physician, who examined it and quite reasonably referred him to an orthopedic surgeon.  The orthopedic surgeon considered ordering an MRI of the knee but worried that insurance would not cover a substantial portion of the $1,500 price tag, so he suggested a less expensive alternative: a six-week course of physical therapy that would cost only $600 – a quite responsible course of action.

At the end of this period of time, Michael was still experiencing pain and intermittent swelling.  The orthopedic surgeon made another quite responsible decision and ordered the MRI exam, which showed a torn meniscus.  The orthopedic surgeon could have recommended arthroscopic surgery, which would have earned him a handsome fee and generated revenue for his physician-owned surgery center.  Instead he again acted quite responsibly, advising Michael that the surgery would actually increase the pain and swelling for a time and probably not improve his long-term outcome.  Based on this advice, Michael declined surgery.

Though everyone in this case proceeded responsibly, the ultimate outcome was inefficient and costly.  Many factors contributed, but perhaps the most important was the fact that Michael’s physician outlined choices based on an inaccurate understanding of the costs associated with his recommendations.  The orthopedic surgeon thought that the cost of six weeks of physical therapy was 60% less than the MRI.  In fact, however, the actual payment for the MRI from the insurance company would be only $300, not the “retail” price of $1,500.  What appeared to be the less expensive option was actually twice as expensive, and it delayed definitive diagnosis by six weeks.

This story is emblematic of a larger problem in contemporary healthcare.  No one – not the patients, the physicians, the hospitals, or the payers – really understands in a thorough way the true costs of their decisions.  After receiving care, patients routinely receive by mail multi-page “explanations of benefits” that show huge differences between list prices and actual payments.  Most find it baffling to try to determine who is paying how much for what.  Physician practices and hospitals get calls every day from panicked patients who believe that they are being billed for exorbitant costs, when in fact most or all of the charges will be paid by insurance at a huge discount.

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Fee for Service vs. Fee for Serving

In a previous blog we demonstrated how guidelines can compromise the care of individual patients when designed to serve the health care system.

Why should treating physicians defer to guideline committees at all, we asked? For decades medical students have been taught to read and understand information from published papers.

We are all trained in critical appraisal and can keep up with the clinically meaningful literature, the literature that is relevant and accurate enough to present to patients. Just because there are nearly 20,000 biomedical journals does not mean that any, let alone all are replete with meaningful information. We can discern the valuable from the not valuable; why do we need others to tell us?

In fact, we even argued in our last post that patients can and should judge the value of medical information. After all, they face the consequences of misinterpreting the likelihoods of benefit and of harm associated with various options for care.

No one remembers the numbers that describe the chances for benefit and harm or ask more questions about the veracity of information than a patient who must choose. The smartest information managers we have ever encountered are our patients; when informed, they quickly determine the validity of the information and apply their personal values to the estimations of the chances for benefit and harm.

Patient Empowerment

Take the example of a patient who recently entered into a therapeutic dialogue with one of us, RAM. This was not the traditional clinical interview. This patient had been diagnosed with prostate cancer and was scheduled for an approach to treatment that the diagnosing physician had offered as the most sensible. However, the decision did not rest easily.

The appointment with RAM was scheduled because the patient sought a dialogue that might offer a chance to reflect on the rationale for the approach he was about to initiate. Two hours into the dialogue, the patient, a 40ish year old African-American man accompanied by his wife, were mulling over the marginal benefits and harms of the options for treating an early stage prostate cancer.

The wife asked how many African-Americans were in the study under discussion. “None”. The husband perked up and then asked, “How many people in the study was my age?” “None”. They then asked if the difference in benefit was a certain, fixed amount? “No, it varies over this range.” – examining the descriptive statistics.

They then asked when the study was started and did it pertain to the present day. “It started over 15 years ago” and the stage of disease of the men in the study was generally more aggressive than in this particular case.

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The Great Coronary Angioplasty Debate: Giving Patients the Right to Speak

Earlier this month, the editors of THCB saw fit to post my essay, “The End of the Era of Coronary Angioplasty.”

The comments posted on THCB in response to the essay, and those the editors and I have directly received, have been most gratifying. The essay is an exercise in informing medical decisions, which is my creed as a clinician and perspective as a clinical investigator.

I use the recent British federal guideline document as my object lesson. This Guideline examines the science that speaks to the efficacy of the last consensus indication for angioplasty, the setting of an acute ST-elevation myocardial infarction (STEMI). Clinical science has rendered all other indications, by consensus, relative at best. But in the case of STEMI, the British guideline panel supports the consensus and concludes that angioplasty should be “offered” in a timely fashion.

I will not repeat my original essay here since it is only a click away. The exercise I display is how I would take this last consensus statement into a trusting, empathic patient-physician discourse. This is a hypothetical exercise to the extent that little in the way of clear thinking can be expected of a patient in the throes of a STEMI, and not much more of the patient’s caring community.

So all of us, we the people regardless of our credentials, need to consider and value the putative efficacy of angioplasty (with or without stenting) a priori. For me, personally, there is no value to be had rushing me from the “door to the balloon” regardless of the speed. You may not share this value for yourself, but my essay speaks to the upper limits of benefit you are seeking in the race to the putative cure by dissecting and displaying the data upon which the British guideline is based.

There is an informative science, most of which cannot deduce any benefit and that which deduces benefit finds the likelihood too remote for me to consider it worth my attempt. A hundred or more patients with STEMI would have to be rushed to the catheterization lab to perhaps benefit one (and to harm more than one).

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Should We Sacrifice Medicine’s Sacred COW?

Chicago Cubs fans of a certain vintage will never forget broadcaster Harry Carey’s signature line, “Holy cow!”  Some have speculated that the exclamation may have originated in Hinduism, one of the world’s major religions, whose adherents worldwide number approximately one billion.  Hindus regard cows as maternal, caring figures, symbols of selfless giving in the form of milk, curds, butter, and other important products.

One of the most important figures in the faith, Krishna, is said to have been a cowherd, and one of his names, Govinda, means protector of cows.  In short, cows are sacred to Hindus, and their slaughter is banned in virtually all Indian states.

Medicine, too, has its sacred cows, which are well known to physicians, nurses, and patients visited by medical teams on their hospital rounds.  In this case, the cow is not an animal but a machine.  In particular, it is the computer on wheels, or COW, a contraption that usually consists of a laptop computer mounted on a height-adjustable pole with a rolling base.  It is used to enter, store and retrieve medical information, including patients’ diagnoses, vital signs, medications, and laboratory results, as well as to record new orders.

As the team moves from room to room and floor to floor, the COW is pushed right along. The COW is often treated with a degree of deference seemingly bordering on reverence.  For one thing, people in hallways and patients’ rooms are constantly making way for the COW.  As an expensive and essential piece of equipment, it is handled gingerly.  Often only the senior member of the medical team or his or her lieutenant touches the COW.

Others know that they have said something important when they see the chief keyboarding the information into the COW.  Sometimes it plays an almost oracular role. When questions arise to which no one knows the answer, such as the date of a patient’s admission or the time course of a fever, they often consult the COW. Just as cows wandering the streets of Indian cities often obstruct traffic, so healthcare’s COWS can and often do get in the way of good medicine. Continue reading…

The End of the Era of Coronary Angioplasty

In a single generation, the evidentiary basis for the practice of medicine has grown from a dream to a massif. No longer need physicians rely solely on experience and opinion in formulating diagnostic and therapeutic approaches to the care of the patient.

However, for any given clinical challenge, the available science is never flawless, monolithic or comprehensive, nor is it likely to be durable in the face of newer studies.

The international medical community has mounted two approaches to sorting the wheat from the chaff: One targets the doctor in convening committees to formulate guidelines for patient care. The other targets the patient for evaluating options, so-called informed medical decision making. Both approaches are now sizable undertakings clothed in organizational imprimaturs and girded by self-promotion.

But they are largely parallel undertakings with work products that can cause considerable cognitive dissonance on the part of the patient and the physician. In a recent article in the British Medical Journal [1] the Guideline Development Group convened by the National Institute for Health and Clinical Excellence (NICE) summarized the thinking behind the guidance it was offering regarding the management of STEMI. This is an object lesson in such cognitive dissonance.

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Target Demographic

He seemed a bit grumpy when he came into the office.  I am used to the picture: male in his early to mid-forties, with wife by his side leading him into the office to “finally get taken care of” by the doctor.  Usually the woman has a disgusted expression on her face as he looks like a boy forced to spend his afternoon in a fabric store with his mother.  My office is the last place he wants to be.

He let himself down on the couch across from my desk with a wince, belying the back pain that brought him here.  He looks around at my office, which is not only a place he didn’t expect to be, but not what he expects a doctor’s office to look like.  First there’s the sofa he is sitting on, which is where my patients spend most of their time during their visits.  Then there is my guitar just behind me.  He and his wife comment on how their daughter would love the fact that I have a guitar, as she is into acoustic guitar music.  Then there’s me, wearing jeans and an untucked button-up shirt, sitting back in my chair and chatting like an ordinary person.  He seems intrigued.

He owns a business, which is a service type business like mine.  Like me, he and his wife choose to do things differently, charging less for folks who can’t afford it.  I chat with him about the stress and strain of owning and running a small business, pointing out how his choice is similar to mine.

He had actually suggested coming to me after he had seen me on television, but obviously had initial doubts as to the accuracy of the report.  Spin happens.  But as we talk, there is much to find in common, and he warms up.  His shoulders relax, he sits back on the couch, and forgets he’s in the doctor’s office.

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Why Can’t We Do Better Than This?

Is there a patient who goes through a hospitalization who does not have stories to tell about the obstacles, errors and indignities that they endured? I just wonder sometimes.

A family relative was hospitalized this week with a stroke at a hospital a few hours from me –and his experience left me demoralized about medicine.

Joe (not his real name) is an 82 year old grandfather, father, husband and one of a kind. He has a scraggly beard and ponytail. He possesses an artistic spirit, but is punctual to a fault – always early, never late. He has an integrity that is rare these days, which led to a loyal following in business and life. And yes, he is devoted to his family.

On Tuesday, he developed some difficulty with his balance. His wife of over 60 years was worried and brought him to the doctor.  That is when the issues began.

Issue #1. His doctor fit him into her schedule and recognized the possibility of the early signs of stroke and sent him for an MR imaging study of his brain. And she also gave him an aspirin, which he promptly took. The problem is that the MR study revealed a small bleed in his brain – and the last thing you want to give someone bleeding in his brain is an aspirin because it can cause more bleeding.

Issue #2. At one of the nation’s most reputable New England hospitals he was evaluated in the Emergency Department and admitted to the hospital. He is brought upstairs to the stroke ward fairly late and he is exhausted. Even later he is told that he must have a CT scan of the brain.

He is stable. His symptoms are not changed. Nevertheless, someone orders a CT scan. There was no discussion about whether he should have the scan with Joe’s family; they were told he needed to have one. After the scan, his family is told that the scan will not be read until the morning when the radiologist arrives. They push and are told that the technician looks at the scan and would let someone know if it looked abnormal.

They push a little more and ask that they speak to someone who is managing his case. A resident arrives and tells them that there is nothing alarming. The family asks if it will be compared with the scan from earlier in the day  (as that was the reason they took the scan 6 hours later) and are told that scan hasn’t been uploaded yet, even though it was with Joe’s records when he was in the Emergency Department.

They ask the resident to retrieve it from the emergency room and make the comparison. Finally they are told that the Radiologist in the ER reviewed it – but when they ask who reviewed it, they are not told a name.

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Patient Engagement: On Metrics and Meaning

What is patient engagement?

Everyone agrees that it’s a good thing, and that we healthcare providers should be fostering it.

How to do so, however, depends on just what you believe patient engagement means.

As Dan Munro recently pointed out, the term “patient engagement” is a hot buzz phrase, and – in the best tradition of such phrases – it’s amorphous enough and appealing enough to mean…just about anything.

Provided that it that makes us feel good about healthcare, of course. Better yet, provided that it casts our favorite healthcare approaches in a favorable light. (Rob Lamberts nicely summarizes some angles of the term here.)

I actually rather liked Munro’s post, titled “Patient engagement: Blockbuster Drug or Snake Oil?” until he got to this part: “We now have some very real metrics around what constitutes real patient engagement and Leonard highlighted two impressive examples.” He goes on to point to two studies of care coordination for chronic illness — one at Kaiser and the other at the VA – and summarizes some key improvements in outcomes.

At Kaiser, they included things like decreased mortality rates and fewer emergencies, as well as improved cholesterol screenings and more people meeting cholesterol goals. With the VA’s Telehealth program, hospital days were reduced and patient satisfaction was 86%. (BTW, I had a VA primary care clinic from 2006-2010, and several of my patients were in Telehealth.)

These are indeed nice results. Still, somehow they didn’t impress me as constituting “real patient engagement.” They seemed more like “real population health management, facilitated by teams, care coordination, communication infrastructure, and organized protocols.”

Shouldn’t real patient engagement mean more than this?

Defining patient engagement

Here’s my current take:

Supporting patient engagement means fostering a fruitful collaboration in which patients and clinicians work together to help the patient progress towards mutually agreed-upon health goals.

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